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0 0 <br /> STATE OF CAUFORMA <br /> STATE WATtA RESOURCES CONTROL®CARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET -5?)-55 VA"T Lp'fic JJ j 1Y) <br /> CITY CA <br /> COUNTY !�PAW �JDAPU I <br /> It. INSTALL. 4TION(mark all that apply): <br /> Th.? installer has been certified by the tank and piping manufacturers. <br /> The installation has been inspected and certified by a registered professional engineer. <br /> D&I TM?installation has been inspected and approved by the implementing agency. <br /> All work listed on the manufacturers installation checklist has been completed. <br /> The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> C3 Another method was used as allowed by the implementing agency. (Please specify.) <br /> III-OATH I Certify that the infor tion ovided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Dale <br /> Print Natne Phone 0Z5 )29>,f-Z- 45.5C->� <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE CO -WRIFIDICT*10"I FACILITY 9 TANK a <br /> TANK I,Q.o <br /> FORM C jlffiiI T iIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 6 UNLEM THEY NAVE BEEN FILED PREVIOUSLY FORaWSC7 <br /> -4SUOO-A-Puam VS0:40 66-10 <br /> dizia AS 150Z u 0& n.A 66-IO-4710 <br /> TOGO NOI539 ZS "N MOIL I T696 Zt9 OTS YVJ LZ:90 INA 66/TO/0T <br />